Artificial chordae deployment

ABSTRACT

A method can comprise advancing a suction cup at a distal end of a suction catheter into a heart chamber, contacting the suction cup to a heart valve leaflet, and partially axially collapsing the suction cup while applying a negative pressure through the suction catheter and the suction cup and contacting the suction cup to the heart valve leaflet.

RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/852,341, filed on Apr. 17, 2020, which is a continuation of U.S.application Ser. No. 15/491,809, filed on Apr. 19, 2017, which claimsthe benefit of U.S. Application No. 62/326,609, filed on Apr. 22, 2016,the entire disclosures all of which are incorporated by reference forall purposes.

FIELD OF THE INVENTION

The various embodiments relate to treatment of mitral valve dysfunctionthrough the placement of artificial chordae between the leaflets and theventricular wall or papillary muscles in general, and more particularlyto replacing the chordae with sutures and pledgets threaded thereon, andfurther to approximating opposing leaflets together.

BACKGROUND INFORMATION 1. Field of the Disclosure

The disclosure herein relates to methods and devices for treating mitralvalve dysfunction through the placement of artificial chordae betweenthe leaflets and the ventricular wall or papillary muscles, while theheart is still beating. The disclosure herein further relates to theplacement of multiple artificial chordae with a single device, and theapproximation of leaflets.

2. Description of the Background

As illustrated in FIG. 1 , the human heart 10 has four chambers, whichinclude two upper chambers denoted as atria 12, 16 and two lowerchambers denoted as ventricles 14, 18. A septum 20 divides the heart 10and separates the left atrium 12 and left ventricle 14 from the rightatrium 16 and right ventricle 18. The heart further contains four valves22, 24, 26, and 28. The valves function to maintain the pressure andunidirectional flow of blood through the body and to prevent blood fromleaking back into a chamber from which it has been pumped.

Two valves separate the atria 12, 16 from the ventricles 14, 18, denotedas atrioventricular valves. The left atrioventricular valve, the mitralvalve 22, controls the passage of oxygenated blood from the left atrium12 to the left ventricle 14. A second valve, the aortic valve 24,separates the left ventricle 14 from the aortic artery (aorta) 30, whichdelivers oxygenated blood via the circulation to the entire body. Theaortic valve 24 and mitral valve 22 are part of the “left” heart, whichcontrols the flow of oxygen-rich blood from the lungs to the body. Theright atrioventricular valve, the tricuspid valve 26, controls passageof deoxygenated blood into the right ventricle 18. A fourth valve, thepulmonary valve 28, separates the right ventricle 18 from the pulmonarytrunk 32. The right ventricle 18 pumps deoxygenated blood through thepulmonary trunk 32 and arteries to the lungs wherein the blood isoxygenated and then delivered to the left atrium 12 via the pulmonaryveins. Accordingly, the tricuspid valve 26 and pulmonary valve 28 arepart of the “right” heart, which control the flow of oxygen-depletedblood from the body to the lungs.

Both the left and right ventricles 14, 18 constitute “pumping” chambers.The aortic valve 24 and pulmonary valve 28 lie between a pumping chamber(ventricle) and a major artery and control the flow of blood out of theventricles and into the circulation. The aortic valve 24 and pulmonaryvalve 28 have three cusps, or leaflets, that open and close and therebyfunction to prevent blood from leaking back into the ventricles afterbeing ejected into the lungs or aorta 30 for circulation.

Both the left and right atria 12, 16 are “receiving” chambers. Themitral valve 22 and tricuspid valve 26, therefore, lie between areceiving chamber (atrium) and a ventricle so as to control the flow ofblood from the atria to the ventricles and prevent blood from leakingback into the atrium during ejection out of the ventricle. Both themitral valve 22 and tricuspid valve 26 include two or more cusps, orleaflets (shown in FIG. 3 ), that are encircled by a variably densefibrous ring of tissues known as the annulus. The valves are anchored tothe walls of the ventricles by chordae tendineae (chordae) 42. Thechordae tendineae 42 are cord-like tendons that connect the papillarymuscles 44 to the leaflets of the mitral valve 22 and tricuspid valve 26of the heart 10. The papillary muscles 44 are located at the base of thechordae 42 and are within the walls of the ventricles. They serve tolimit the movements of the mitral valve 22 and tricuspid valve 26 andprevent them from inverting. The papillary muscles 44 do not open orclose the valves of the heart, which close passively in response topressure gradients; rather, the papillary muscles 44 brace the valvesagainst the high pressure needed to circulate the blood throughout thebody. Together, the papillary muscles 44 and the chordae tendineae 42are known as the subvalvular apparatus. The function of the subvalvularapparatus is to keep the valves from prolapsing into the atria when theyclose.

The tricuspid valve 26 in FIG. 1 typically is made up of three leafletswith three papillary muscles. However, the number of leaflets can rangebetween two and four. The three leaflets of the tricuspid valve 26 arereferred to as the anterior, posterior, and septal leaflets. Althoughboth the aortic and pulmonary valves each have three leaflets (orcusps), they do not have chordae tendineae. The mitral valve 22 has twopapillary muscles 44, the anteromedial and the posterolateral papillarymuscles, which attach the leaflets 52, 54 to the walls of the leftventricle 14 via the chordae tendineae 42.

FIG. 2 is an illustration of a cutaway anterior view of the “left heart”200 in systole, as indicated by the contracted ventricular wall 201.Illustrated in FIG. 2 is the mitral valve 22 having a posterior leaflet203 and an anterior leaflet 204, the mitral valve in a closed position.Also visible is the aortic valve 24 which is an open configurationduring systole, and permits bloodflow from the left ventricle 14 to theaorta 30. During systole, when a healthy mitral valve is closed, blooddoes not flow from the left atrium 12 to the left ventricle 14.

As illustrated with reference to FIG. 3 , a top view of a healthy mitralvalve 22, the mitral valve 22 includes two leaflets, the anteriorleaflet 204 and the posterior leaflet 203, and a diaphanous incompletering around the valve, called the annulus 205. The vast majority ofpatients undergoing valve surgery, such as mitral valve surgery, sufferfrom a degenerative disease that causes a malfunction in a leaflet ofthe valve, which results in prolapse and regurgitation.

One possible malfunction of a heart valve, valve regurgitation, occurswhen the leaflets of the valve do not close completely thereby causingblood to leak back into the prior chamber. This type of valvemalfunction typically occurs with the mitral valve and tricuspid valve.

There are three mechanisms by which a valve becomes regurgitant orincompetent; they include Carpentier's type I, type II and type IIImalfunctions. A Carpentier type I malfunction involves the dilation ofthe annulus such that normally functioning leaflets are distracted fromeach other and fail to form a tight seal (e.g., do not coapt properly).Included in a type I mechanism malfunction are perforations of the valveleaflets, as in endocarditis. A Carpentier's type II malfunctioninvolves prolapse of one or both leaflets above the plane of coaptation.This is the most common cause of mitral regurgitation, and is oftencaused by the stretching or rupturing of chordae tendineae normallyconnected to the leaflet. A Carpentier's type III malfunction involvesrestriction of the motion of one or more leaflets such that the leafletsare abnormally constrained below the level of the plane of the annulus.Leaflet restriction can be caused by rheumatic disease (IIIa) ordilation of the ventricle (IIIb).

FIG. 4 illustrates a prolapsed mitral valve 22. Here, even when insystole, when the anterior 204 and posterior 203 leaflets should be incontact with each other, gap 208 remains between the two. Because one ormore of the leaflets 203, 204 malfunction, the prolapsed mitral valve 22does not close properly, and, therefore, the leaflets fail to coapt.This failure to coapt causes a gap 208 between the leaflets 203, 204that allows blood to flow back into the left atrium, during systole,while it is being ejected out of the left ventricle. This can create aregurgitation or other mitral valve insufficiency. FIG. 4 furtherillustrates the valve annulus 205.

Although stenosis or regurgitation can affect any valve, stenosis ispredominantly found to affect either the aortic valve 24 or thepulmonary valve 28, whereas regurgitation predominantly affects eitherthe mitral valve 22 or the tricuspid valve 26. Both valve stenosis andvalve regurgitation increase the workload on the heart 10 and can leadto very serious conditions if left un-treated; such as endocarditis,congestive heart failure, permanent heart damage, cardiac arrest, andultimately, death. Since the left heart is primarily responsible forcirculating the flow of blood throughout the body, malfunction of themitral valve 22 or aortic valve 24 is particularly problematic and oftenlife threatening. Accordingly, because of the substantially higherpressures on the left side of the heart, left-sided valve dysfunction ismuch more problematic.

All of the references cited in this application are incorporated byreference in their entireties.

SUMMARY OF THE INVENTION

The present application describes methods and devices for minimallyinvasive, beating-heart, valve repair, including but not limited tomitral valve repair.

Valve dysfunction can be treated through the placement of artificialchordae between the leaflets and the ventricular wall or papillarymuscles or the approximation of leaflets.

An expandable element can be inserted through a valve leaflet, such as amitral valve leaflet, in order to connect the leaflet to other tissue ofthe heart, including other leaflets. Artificial chords can be secured tothe leaflets without relying on additional manipulations on the atrialside of the valve leaflets.

The exemplary embodiments disclosed herein refer to an apparatus havingat least two pledgets, a first line, and at least a second line. Thefirst line can have a first end connected to a first of the at least twopledgets and a second end connected to a second of the at least twopledgets. The second line can be connected to the first line. The atleast two pledgets and the first and second lines can be positionedinside a hollow elongate tube. The hollow elongate tube can be a needle.

The exemplary embodiments disclosed herein refer to a method having thesteps of introducing a needle into a heart ventricle; contacting theventricular side of a heart valve leaflet with the needle; piercing theheart valve leaflet with the needle so that at least a portion of theneedle extends through the heart valve leaflet; deploying a pledget witha line attached to it on the atrial side of the heart valve leaflet; andwithdrawing the needle from the heart valve leaflet back into theventricle. The needle can have an opening such that when the needlepierces the leaflet, the portion of the needle with the opening passesthrough to the atrial side of the heart valve leaflet. The pledget andline attached to the pledget can be deployed from the needle through theopening.

The exemplary embodiments disclosed herein further refer to a methodhaving the steps of introducing a catheter with a suction cup at itsdistal end into a heart ventricle proximate to a heart valve leaflet;contacting a ventricular side of the heart valve leaflet with a distalend of the suction cup; applying a negative pressure to the ventricularside of the heart valve leaflet; extending a needle out of the distalend of the catheter and suction cup; piercing the heart valve leafletwith the needle, deploying a pledget through the opening of the needleon the atrial side of the heart valve leaflet; withdrawing the needlefrom the heart valve leaflet into the catheter; and releasing thenegative pressure to remove the suction cup from the ventricular side ofthe heart valve leaflet. The needle can be positioned within thecatheter. The needle has an opening, and when the leaflet is piercedwith the needle, the opening in the needle passes through the leaflet tothe other side of the leaflet. A line is secured to the pledget. Whenthe needle is withdrawn from the leaflet, the pledget and at least aportion of the line that is secured to the pledget remain on the otherside of the leaflet.

The exemplary embodiments disclosed herein further refer to a method ofcoapting valve leaflets having the steps of introducing into a needleinto a heart ventricle; contacting a ventricular side of a first heartvalve leaflet with the needle; piercing the first heart valve leafletwith the needle; withdrawing the needle from the first heart valveleaflet contacting a ventricular side of a second heart valve leafletwith the needle; piercing the second heart valve leaflet with theneedle; deploying a second pledget through the opening of the needle onthe atrial side of the second heart valve leaflet; withdrawing theneedle from the second heart valve leaflet; and withdrawing the needlefrom the ventricle. Piercing the leaflets includes pushing at least aportion of the needle all the way through to the space on the other sideof the leaflet. The needle can have an opening, and the portion of theneedle with the opening can be pushed through to the other side of theleaflet. The other side of the leaflet can be the atrial side of theleaflet, when the needle makes initial contact with the ventricular sideof the leaflet prior to piercing. Deploying a pledget includes deployinga pledget from the opening in the needle. A line can be attached to thepledget such that both the pledget and a portion of the line remain onthe other (for example, atrial) side of the leaflet. After the needle iswithdrawn from one leaflet, it can pierce a second leaflet, and themethod can repeat so that a second pledget and a portion of the lineremains on the other (for example, atrial) side of the second leaflet.

These and aspects of the exemplary embodiments will become apparent fromthe following detailed description, taken in conjunction with theaccompanying drawings, illustrating by way of example the principles ofthe various exemplary embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

In order to facilitate a fuller understanding of the exemplaryembodiments, reference is now made to the appended drawings. Thesedrawings should not be construed as limiting, but are intended to beexemplary only.

FIG. 1 depicts a cut-away anterior view of the human heart in diastole.

FIG. 2 depicts a cut-away anterior view of the left portion of a humanheart in systole.

FIG. 3 depicts a top view of a healthy mitral valve with the leafletsclosed.

FIG. 4 depicts a top view of a dysfunctional mitral valve with a visiblegap between the leaflets.

FIG. 5 depicts a perspective view of a needle with pledgets inaccordance with an exemplary embodiment.

FIG. 6 depicts a perspective view of a needle with a pledget and a linein accordance with an exemplary embodiment.

FIG. 7 depicts a side view of a needle in accordance with an exemplaryembodiment.

FIGS. 8A and 8B depict views of a needle with a puncturing tip retractedand exposed, respectively, in accordance with an exemplary embodiment.

FIGS. 9A-9F depict a needle approaching and puncturing cardiac tissue,deploying a pledget, and removal of a needle in accordance with anexemplary embodiment.

FIG. 10A depicts a cutaway anterior view of a human heart with a pledgetand line implanted in accordance with an exemplary embodiment.

FIG. 10B depicts a top view of the pledget of FIG. 10A, on top of amitral valve leaflet.

FIG. 11 depicts an exemplary embodiment of a method of implantation inaccordance with the exemplary embodiment of FIGS. 10A and 10B.

FIG. 12A depicts a cutaway anterior view of a human heart with aplurality of pledgets in accordance with an exemplary embodiment.

FIG. 12B depicts a top view of the pledgets of FIG. 12A and leaflets ofa mitral valve leaflet.

FIG. 12C depicts a close-up of a portion of the view of FIG. 12A.

FIG. 13 depicts an exemplary embodiment of a method of implantation inaccordance with the exemplary embodiment of FIGS. 12A and 12B.

FIG. 14A depicts a cutaway anterior view of a human heart with aplurality of pledgets and sutures in accordance with an exemplaryembodiment.

FIG. 14B depicts a top view of the pledgets of FIG. 14A and leaflets ofa mitral valve.

FIG. 15 depicts an exemplary embodiment of a method of implantation inaccordance with the exemplary embodiment of FIGS. 14A and 14B.

FIG. 16A depicts a cutaway anterior view of a human heart with aplurality of pledgets and sutures in accordance with an exemplaryembodiment.

FIG. 16B depicts a top view of the pledgets of FIG. 16A and leaflets ofa mitral valve.

FIG. 16C depicts a close-up of a portion of the view of FIG. 16A.

FIG. 17A depicts a cutaway anterior view of a human heart with pledgetscoapting mitral valve leaflets together in accordance with an exemplaryembodiment.

FIG. 17B depicts a top view of the pledgets of FIG. 17A and leaflets ofa mitral valve.

FIG. 18 depicts a close-up of a portion of the view of FIG. 17A.

FIGS. 19A and 19B are side cross sections of an embodiment of anartificial chord delivery device.

FIG. 20 illustrates an embodiment of a transventricular wall approachfor the artificial chord delivery device shown in FIGS. 19A and 19B.

FIG. 21 illustrates an embodiment of a transseptal approach for theartificial chord delivery device shown in FIGS. 19A and 19B.

FIG. 22 illustrates an alternative transventricular wall approach forthe artificial chord delivery device shown in FIGS. 19A and 19B.

FIG. 23 illustrates an example of an artificial chord placed using theartificial chord delivery device.

DETAILED DESCRIPTION OF EMBODIMENTS

The following description is intended to convey a thorough understandingof the embodiments by providing various embodiments and detailsinvolving a device and method for delivering a suture line and pledgetsto repair a mitral valve by replacing one or more chordae with sutureline. In various embodiments, the device can also be used in a methodfor approximating the valve leaflets together. It is understood,however, that the invention is not limited to these specific embodimentsand details, which are exemplary only. It is further understood that onepossessing ordinary skill in the art, in light of known devices, systemsand methods, will appreciate the use of the invention for its intendedpurposes and benefits in any number of alternative embodiments.

There is a significant need to perform mitral valve repairs using lessinvasive procedures while the heart is still beating. Accordingly, thereis a continuing need for new procedures and devices for performingcardiac valve repairs, such as mitral and tricuspid valve repairs, whichare less invasive, do not require cardiac arrest, and are lesslabor-intensive and technically challenging. Chordal replacementprocedures and artificial chordae that ensure the appropriate chordallength and spacing so as to produce a competent valve are of particularinterest. The methods and repair devices presented herein meet theseneeds.

Repair of the chordae of a cardiac valve, such as that provided by themethods described herein, assist the valve leaflets such that they canmeet in the correct position, and the valve can once again functionproperly. This will repair the leaking of the valve, and then in turnalleviate the symptoms associated with such leaking, regurgitation, orother insufficiency.

Referring to FIGS. 5, 10A, and 10B, the exemplary embodiments disclosedherein use a needle 501 such as a hypotube needle, loaded with a line507 of chordae replacement material, such as a strand of suture line.The line 507 can be any of a suture, suture line, strand, and/orartificial chordae. The line can be made from a wide variety ofdifferent materials. For example, the line 507 can be made of ePTFE orother chordae replacement material with one or more pledgets threadedonto the line. For a ventricular approach, the needle is passed into theheart and through the valve leaflet at the desired location.

Referring to FIG. 5 , an exemplary embodiment of a hypotube needle 501is illustrated. The hypotube needle 501 of FIG. 5 has a sharpened tip502 and is generally hollow and cylindrical in an exemplary embodiment,with an angled distal end. Inside the needle are a plurality of pledgets503, 504, 505 which are rolled, folded, or in any other storage orcompressed configuration to allow for storage inside the needle and easydeployment. There can be any number of pledgets. The pledgets 501 areconnected to one or more lines 507. The configuration of the pledgetsand/or the line(s) can be adjusted based on the application. Forexample, the pledget can be rectangular (see FIG. 6 ) and can becompressed or rolled (see FIG. 5 ) to fit within the needle. Groups oftwo or more pledgets can be provided on a strand 507, allowing for thegroups of pledgets to be pulled taught at specific locations. Thepledgets 503, 504, 505 can be attached to each other by a line 507, orat least one pledget can be attached to at least one separate line. Theline 507 can be secured to the distal most pledget at 503 and slidablyrun through a center or other location 522 of each of the moreproximally located pledgets in the needle as illustrated. The line canbe secured (e.g., not slideable) to both the distal-most pledget and theproximal-most pledget. A separate strand 507 can be connected to eachpledget 503, 504, 505, or one strand can be connected to two or morepledgets. The pledgets can be crimped and compressed to occupy lessvolume in a central shaft of the needle, allowing for a reduced outerdiameter of the needle 501.

Referring to FIG. 6 , a perspective view of a hypotube needle 601, aline 607, and a deployed and expanded pledget 602 in accordance with anexemplary embodiment is illustrated. The pledget 602 can be square orrectangular in shape, or can be circular or any other shape. Forexample, the pledget can have a generally flat top surface area andbottom surface area, so as to allow the pledget to act as an anchor onone side of heart tissue 905 (see FIG. 9F). The pledget 602 can be anymaterial suitable for implantation and that is biocompatible, such asPTFE, ePTFE, felts made of PTFE and/or ePTFE, polyester, polyethyleneterephthalate (PET, DACRON®), or other polymer. The strand can extendthrough the pledget, and can be secured by a knot or other means asindicated at 620. In the exemplary embodiment of FIG. 6 , the pledget603 and line can be deployed by pushing the pledget out a distal opening606 in the needle 601 in exemplary embodiments. The line can be made ofany suitable material, for example, PET, ePTFE, or PTFE.

Referring to FIGS. 6 and 7 , the pledget 603 and line 607 can also bedeployed by pushing the pledget out a side opening 704 of a needle 701.In the example illustrated by FIG. 7 , hypotube needle 701 can have atapered or conical tip 702 at the distal end, for penetrating anddilating tissue. Hypotube needle 701 also has a hollow central lumen 705and a generally cylindrical body 703. Pledgets can be stored in thecentral lumen 705 in the manner illustrated in FIG. 5 or in any othermanner. The opening 704 is in the side of the cylindrical body justproximal to the conical tip 702. The opening 704 is in fluid connectionwith the central shaft, in which the pledget(s) and line(s) can bedispensed through. The needle can be made of stainless steel or anyother suitable material for needles for surgical use.

FIGS. 8A and 8B are perspective views of an embodiment of a needle 801.In the example illustrated by FIGS. 8A and 8B the hypotube needle 801has a conical distal portion 802, and side opening 803 for thedeployment of lines and pledgets, and an opening at the distal end 804of the conical distal portion 802. FIG. 8B illustrates the same needleas FIG. 8A, where the opening 804 at the distal end 804 of the conicaltip has a piercing element 805 extending therefrom. The piercing element805 can be an auto incisor in an exemplary embodiment. The auto incisorcan be a spring-loaded retracting point or blade, which allows theplacement of the blunt tip of distal portion 802 against the cardiactissue to be punctured, the location to be verified, and the puncture ofthe tissue to occur only when the piercing element 805 is extended by anactuator. FIG. 8A illustrates the needle with the auto incisorretracted, and FIG. 8B illustrates the auto incisor in a deployedposition. The needle in FIGS. 8A and 8B can be used in any of theprocedures described herein, including but not limited to insertingartificial chordae and securing opposing edges of two or more leafletstogether.

FIGS. 9A-9F illustrate the steps involved in the deployment of a line909 and single pledget 906 in a cardiac tissue 905. For example, a valveleaflet, such as a mitral valve leaflet or a tricuspid valve leaflet.The line 909 can be used as an artificial mitral valve or tricuspidvalve cord or to secure two or more leaflets together (e.g., Alfieriprocedure). In this embodiment, a shafted instrument 901, which can be ahyponeedle, is inserted into the cardiac tissue 905 to deploy a pledget906. In the example, the needle 901 has a conical distal end 902 with anopening 904 towards the distal-most end 912, which is flat or otherwisenon-tissue-piercing, and a side opening 910 along a hollow shaft 911.However, any of the needles disclosed herein can be used to perform themethod illustrated by FIGS. 9A-9F. In FIG. 9A, the flat distal tip 912is brought close to the cardiac tissue 905, which can be mitral valveleaflet tissue. FIG. 9B illustrates the same needle 901 after it hasbeen moved closer to the tissue, and flat distal tip 912 now makescontact with tissue 905. FIG. 9C illustrates a needle 901 with apiercing element 913 extended from the distal end of the conicalportion, puncturing the tissue 905 as illustrated herein. FIG. 9Dillustrates the needle 901 with the conical tip 902 and the side opening910 fully inserted through the cardiac leaflet tissue 905. FIG. 9Eillustrates a pledget 906 attached to a line 909 deployed such that thepledget is in an expanded configuration. FIG. 9F illustrates thewithdrawal of the needle 901 from the cardiac leaflet tissue 905 andpulling the line 909. For example, the line can pull the pledget 906against leaflet tissue 905.

Referring to FIG. 10A, in an exemplary embodiment, the pledget 1001abuts the atrial side of a mitral valve leaflet 1005. The pledget can bebrought into contact with the atrial side of the leaflet 1005, forexample, once the delivery device or needle 901 has been removed fromthe heart ventricle or after the needle has been removed from theleaflet 1005. The line 1002 is then pulled taught, and the line isanchored to the outside of the ventricular wall at or near the point ofentry into the ventricle, for example, the apex, with an anchor 1004.

FIGS. 10A-10B illustrate an exemplary embodiment of a single pledgetinserted into the mitral valve leaflet tissue. In FIG. 10A, a singlepledget 1001 attached to a single line 1002 has been implanted. The line1002 is visible in the left ventricle of this cutaway anterior view ofthe human heart. The line is anchored into the ventricular wall 1003 ofthe left ventricle. The anchor 1004 can also be placed into or throughthe papillary muscle at the discretion of the user. The anchor can beanother pledget in an exemplary embodiment. The anchor can be any one orplurality of a pledget, knot, clip, disc, hook, barb, and/or adhesive.Any device capable of securing the line 1002 to the heart tissue can beused. The line can replace or work in conjunction with existing chordae.

FIG. 10B illustrates the top view of the mitral valve, with the pledget1001 abutting the atrial surface of the anterior leaflet 1005 of themitral valve. In FIGS. 10A-10B, a single pledget is deployed from aneedle, and the line is anchored via anchoring element 1004 near theoutside of the apex of the heart such that the line is of an appropriatelength to be a replacement or supplemental chordae in the ventricle ofthe heart. In an exemplary embodiment, the leaflet 1005 is imaged andthe length of the line 1002 is adjusted to reduce or eliminate prolapseof the leaflet 1005 and/or the gap 208 illustrated by FIG. 10B. Forexample, a leaflet may be imaged by echocardiography (echo), which canalso be used to detect regurgitation.

An exemplary method for inserting the pledgets and line by deploying theline and at least one pledget from a hypotube needle as illustrated inFIGS. 10A-10B is shown in FIG. 11 . In step 1101, the needle, which canbe contained within a delivery device, can be inserted through theventricle of the heart, near the apex of the heart or any other locationas deemed appropriate by the user. The needle is passed into the heartand through the valve leaflet to the desired location. Assistance inpositioning the needle can be provided by exemplary embodiments of adeployment device with an outer catheter and a suction cup as disclosedherebelow and illustrated in FIGS. 19-23 . In step 1102, the needle isbrought to the ventricular surface of a valve leaflet. In step 1103, theneedle punctures the leaflet tissue until an opening in the needle is onthe atrial side of the leaflet. The puncturing of the leaflet can beaccomplished using an optional piercing element at the distal end of theneedle. In step 1104, a most distal pledget and at least a portion ofthe line in the needle is deployed on the atrial side of the leaflet. Instep 1105, the needle is retracted from the leaflet, and then from theventricular wall. Here the line is set to its desired length, and theline, now acting as an artificial chord, can be anchored in step 1107 tothe ventricular access location with an anchor. In one exemplaryembodiment, in optional step 1106, the valve is viewed to confirm thatthe leaflets are coapting while the heart is beating and the length ofthe line is adjusted if necessary.

FIGS. 12A-12C illustrate another exemplary embodiment of pledgets 1201,1202, 1203 and lines inserted to replace or work in conjunction with achordae attached to the left ventricle and mitral valve leaflets. FIG.12A depicts a cutaway anterior view of the human heart, with a singlelonger line, and a plurality of shorter lines that are each connected toa pledget. FIG. 12C illustrates a close-up of a portion of FIG. 12A. Inthis configuration, each pledget 1201, 1202, 1203, is fixedly attachedto a shorter line. The shorter lines 1208, 1209, and 1210, attached toeach pledget, 1201, 1202, and 1203, respectively, are all connected to alonger line 1204. The first pledget 1201 is dispensed through, forexample, an opening 704 in a needle 701 of FIG. 7 . The needle is thenremoved from the leaflet tissue and reinserted into the leaflet tissue.Once the opening of the needle is again on the atrial side of theleaflet, a second pledget 1202 is dispensed. The needle is againwithdrawn from the leaflet. The needle can be inserted into the leafleta third time and a third pledget 1203 is dispensed into the mitral valveleaflet. Any number of pledgets can be deployed in this manner. Once thepledgets have been deployed, the needle is again removed from theleaflet. The three lengths of suture line 1208, 1209, and 1210, can besecured to each other and to the longer line 1204, by a connector 1211.The connector can also be stored in the needle for deployment into theheart. The device used to deploy the pledgets and line is withdrawn fromthe ventricular wall of the heart, and the line 1204 is pulled so thatthe pledgets are all pulled into contact with the atrial side of theleaflet. The proximal end 1205 of the line 1204 can be secured againstthe outside of the heart wall 1206 with an anchor 1207 that can be usedto adjust the line to its optimal length to have a desired therapeuticeffect on the heart valve leaflets and serve as a replacement orcomplimentary to the chordae to the mitral valve. FIG. 12B illustrates atop view (e.g., from the atrial side) of the mitral valve leaflets, withthe first, second, and third pledgets 1201, 1202, 1203 in position inthe anterior leaflet 1208.

An exemplary method for deploying pledgets in the configurationdisclosed in FIGS. 12A-12C, is shown in FIG. 13 . In step 1301 of thisexemplary embodiment, the device is inserted through the ventricularwall. In step 1302, the needle is brought to the leaflet tissue on theventricular side of the leaflet. Assistance in positioning the needlecan be provided by exemplary embodiments of a deployment device with anouter catheter and a suction cup as disclosed herebelow and illustratedin FIGS. 19-23 . In step 1303, the needle punctures the leaflet andextends through it. In step 1304, a first pledget, securely attached tothe line, is deployed. In step 1305, the needle is removed from theleaflet but is not fully withdrawn from the ventricle. Steps 1303through 1305 are repeated until a desired number of pledgets and lineshave been deployed in the leaflet tissue. A connector piece holds thelines secured to the pledgets together. The connector piece can bedispensed from the needle in the heart ventricle after any withdrawal ofthe needle from the leaflet. The connector can also be deployed from theneedle prior to any contact of or insertion of the needle into theleaflet. The needle and delivery device can be removed from the heart instep 1306. In step 1308, the length of the suture line (or lines) areadjusted so that it is (they are) taught when the valve leaflet is inthe closed position. In one exemplary embodiment, the valve is viewed toconfirm that the leaflets are coapting while the heart is beating, andthe length of the line is adjusted if necessary, shown in step 1307.FIG. 12A illustrates a plurality of pledgets deployed by this method.

FIGS. 14A-14B illustrate another exemplary embodiment of using pledgets1401 and 1402, and lines 1403, 1404 to repair a mitral valveinsufficiency or regurgitation. FIG. 14A illustrates another exemplaryembodiment of the implantation of the pledgets. In this embodiment, asingle line can be used to deploy pledgets 1401, 1402. The device hasbeen inserted through the ventricular wall, the needle inserted throughthe anterior mitral valve leaflet, and a pledget 1401 deployed. Thedevice is then removed through the ventricular wall, and the line 1403secured with an anchor 1411. The device is then reinserted through theventricular wall at approximately the same or the exact same location asthe first time, then the needle is brought up to the posterior leaflet,puncturing it and deploying another pledget 1402. The needle and deviceare then retracted from the heart, and the line 1404 is secured withanchor 1411. In this way, a plurality of lines 1403, 1404, can beimplanted in the heart's ventricle, all from a single piece of sutureline, and tethered at the same anchoring location 1410. Any number ofpledgets and lines can be deployed. FIG. 14B illustrates a top view ofthe mitral valve, having a pledget 1401 abutting the atrial side of theanterior leaflet 1408, and a pledget 1402 abutting the atrial side ofthe posterior leaflet 1409.

FIG. 15 illustrates an exemplary embodiment of a method for inserting aplurality of pledgets off of a single line. Multiple lines can bepositioned in the heart, from a single anchoring location. Assistance inpositioning the needle can be provided by exemplary embodiments of adeployment device with an outer catheter and a suction cup as disclosedherebelow and illustrated in FIGS. 19-23 . Once a first pledget and linehave been positioned, as in steps 1101 through 1106 of FIG. 11 , thedevice can be pulled back through the ventricle, in step 1501, and theline can be held external to the heart while the device is passed backinto the ventricle. In step 1502 the needle is brought into contact withthe leaflet tissue in a desired location. In step 1503, the needlepunctures the valve leaflet again; and in step 1504 another pledget isdeployed on the atrial side of the leaflet. In step 1505, the needle isremoved from the leaflet, and in step 1506, the needle and device arewithdrawn back through the ventricular wall. In this way, a plurality ofpledgets, and a plurality of lines, can be positioned in the heart, allfrom a single piece of line. In step 1508, the lines are anchored to theoutside of the heart wall. This process of steps 1501 through 1508 canbe repeated as many times as needed to deploy a plurality of pledgetsinto a leaflet. In one exemplary embodiment, the valve is viewed toconfirm that the leaflets are coapting while the heart is beating andthe length of the lines is adjusted if necessary, in step 1507. Thevalve can be viewed after each instance in which the needle is removedfrom the heart wall, or at any time during the procedure. FIG. 14Aillustrates a plurality of pledgets deployed by this method.

FIGS. 16A-16C illustrate an insertion of pledgets 1601, 1602, 1603,1604, and 1605, and lines 1610, 1611, 1612, 1613, 1614, 1615, and 1616,involving a combination of the methods described above. Here, a firstinsertion of the device is made in the ventricular wall, and a pluralityof pledgets are deployed by the needle into the anterior leaflet of themitral valve while the needle remains in the ventricle, consistent witha method disclosed in FIGS. 12A, 12B, and 13 . Assistance in positioningthe needle can be provided by exemplary embodiments of a deploymentdevice with an outer catheter and a suction cup as disclosed herebelowand illustrated in FIGS. 19-23 . Then the device can be withdrawn fromthe ventricle, so that the line can be tethered or anchored to theventricular wall of the heart. The device can then be inserted againthrough the ventricle, this time with the needle puncturing theposterior leaflet of the mitral valve, and deploying a plurality ofpledgets. In FIGS. 16A-16C, three pledgets 1601, 1602, 1603 have beendeployed into the anterior leaflet and two pledgets 1604, 1605 have beendeployed into the posterior leaflet, but any number and combination ofpledgets can be used. FIG. 16C is a close-up view of a portion of FIG.16A. The pledgets can be deployed in any order. For example, allpledgets deployed in the anterior valve can be deployed followed bydeployment of all pledgets into the posterior valve; the posterior valvepledgets can be deployed before the anterior valve pledgets; or thepledgets be deployed in an alternating manner between the leaflets. Thelines secured to pledgets can be connected by connectors 1606, 1607. Allof the pledgets can be deployed from the same line, or a new line can beused each time the device is deployed into the ventricle. In anexemplary embodiment, lines 1610-1616 are all of the same line of suturematerial. As with FIGS. 12A-12B and 13 , connectors 1606, 1607 can bedispensed from the needle after any withdrawal of the needle from, orprior to the first insertion of the needle to, the anterior leaflet. Aconnector can be dispensed from the needle after any withdrawal of theneedle from, or prior to the first insertion of the needle into, theposterior leaflet.

FIGS. 17A-17B and 18 depict pledgets 1704 1702 and line 1710 deployed inanother manner in accordance with an exemplary embodiment. Theillustrated pledgets and line approximate the function of an Alfieristitch procedure. In FIGS. 17A and 18 , a cutaway anterior view of thehuman heart, two pledgets 1701, 1702 have been inserted, connected by aline 1710. FIG. 18 is a close-up view of a portion of FIG. 17A. Here asingle pledget 1701 is positioned such that it abuts the atrial side ofthe anterior leaflet 1708 of the mitral valve, and a single pledget 1702is positioned such that it abuts the atrial side of the posteriorleaflet 1709 of the mitral valve. The line 1710 extends around theventricular side of the valve leaflets 1708, 1709. The line 1710 ispulled tight to pull the centers of the leaflets 1708 and 1709 together.A connector 1720 is placed on the ventricular side of the leaflet 1709to keep the line 1710 tight. The pledgets 1708, 1709 and line or suture1710 coapt the leaflets together to resolve a mitral valve regurgitationor insufficiency.

The pledgets and line can be initially implanted in the same way as theprevious configurations. That is, the device can be inserted through theventricular wall, and the needle punctures a first leaflet of the mitralvalve, followed by a deployment of a first pledget, which is secured tothe end of a line. The needle is then withdrawn from the leaflet, andthe line can be pulled so that the pledget abuts the atrial side of theleaflet. Then the needle is inserted into the second leaflet of themitral valve, and a second pledget is deployed. The needle is removedfrom the second leaflet, and the line is pulled taught such that thesecond pledget abuts the atrial side of the second leaflet. The line canbe secured to the second pledget by the connector 1720 so that once bothpledgets are deployed, the line that connects them is on the ventricularside of the mitral valve, and the device can be withdrawn from the heartthrough the ventricular wall without any further manipulation of line orpledget. The line can also be slidably engaged with the second pledget,and tied, anchored, or otherwise secured against the ventricular side ofthe mitral valve. Once the needle has been removed from the secondleaflet, the line can be sized to the appropriate length. Again, aconnector 1720 attached to the suture can be stored in the needle anddispensed in the ventricle of the heart either prior to any insertion ofthe needle into a leaflet, or after any withdrawal of the needle from aleaflet.

FIG. 17B depicts a top view of a mitral valve where a pledget 1701 onthe anterior leaflet 1708 and a pledget 1702 on the posterior leaflet1709 are abutting the atrial side of the leaflets and are connected onthe ventricular side by a suture. The anchoring knots 1711, 1712 of thesuture line are visible on top of each of the pledgets. The pledgets canalso be secured to the suture in any other suitable way. In FIG. 17B,the valve leaflets are coapted together to hold the centers of the valveleaflets together. The portions of the valve leaflets 1708, 1709, oneither side of the pledgets 1701, 1702 will open and close to allow themitral valve to function. Any number of pairs of pledgets attached by asuture line can be deployed.

Referring to FIGS. 19A and 19B, in one exemplary embodiment, the leaflet1901 is in a temporarily fixed position, so that the needle 1906 can bebrought into stable contact with the leaflet 1901 at the desiredlocation on the leaflet. A wide variety of different devices can be usedto hold the leaflet 1901. In an exemplary embodiment, a catheter 1902with a collapsible suction cup 1904 at the distal end thereof is used totemporarily engage or hold at least a portion of the valve leaflet in afixed position. The suction catheter 1904 can be used in any of theprocedures and devices described herein. Once engaged or held, theleaflet can be punctured with a needle 1906, and a pledget 1920 with aline attached thereto can be deployed, using the methods disclosedherein.

FIGS. 19A and 19B illustrate an exemplary embodiment of a side crosssection of a distal end of a delivery device 1900 while engaged with anatrioventricular heart valve leaflet 1901, for example, a mitral valveleaflet. The delivery device includes an elongate outer catheter 1902that is deployable using a minimally invasive procedure to the heartvalve leaflet. For example, the catheter can be deployed transapicallyor transseptally. A suction or vacuum catheter 1905 extends through theouter catheter 1902. A proximal end of a lumen of the suction catheter1905 is fluidly coupled to a source of suction or vacuum (notillustrated). In one exemplary embodiment, the suction catheter 1905 isfilled with a liquid, such as water, blood, or a saline solution. In oneexample, the suction catheter 1905 contains substantially no air whenintroduced. A suction cup 1904, such as a frustoconical suction cup,extends from a distal end of the suction catheter 1905. In theillustrated embodiment, the suction cup 1904 is collapsible and isextendable out of and retractable into the outer catheter 1902. Someembodiments of the deployed suction cup 1904 are at least partiallyaxially collapsible when engaging tissue under suction (suctionindicated by arrows 1930). FIG. 19B shows the delivery device 1900having the deployed suction cup 1904 partially axially collapsed. Thedevice also includes a needle catheter 1907 through which a slidableneedle 1906 advances through or retracts from the leaflet 1901. In theillustrated embodiment, the needle catheter 1907 is generally coaxialwith the outer catheter 1902, but is offset in other embodiments. A lineextends through and out of a lumen in the slidable needle 1906. Otherembodiments include at least one additional slidable needle, whichpermits placing multiple lines in a single operation, or selecting theneedle at the more desired position for placing the artificial chord.Some embodiments of the delivery device include an imaging element, forexample, an ultrasound transducer, the use of which will be apparentfrom the following discussion. The needle catheter 1907 can also fit ahypotube needle such as the exemplary embodiments disclosed herein inFIGS. 5-7, 8A-8B, which can contain one or more pledgets to be dispensedtherefrom.

In an embodiment of a method for placing an artificial chord 1908 usingthe delivery device of FIGS. 19A and 19B as an example, a distal endportion of the outer catheter 1902 is positioned in proximity of alocation on a leaflet 1901 needing an artificial chord, for example,under echo or fluoroscopic guidance. The suction cup 1904 is extendedfrom the distal end of the outer catheter 1902, either in closeproximity to or at least partially contacting the leaflet 1901. Suctionor vacuum is then applied through the lumen of the suction catheter1905, which pulls the leaflet 1901 against an opening or distal end ofthe suction cup 1904, thereby capturing and holding the leaflet 1901.Capture can be confirmed by imaging, for example, echo or fluoroscopy.If the leaflet is not captured at the desired location, the suction isreleased or reduced sufficiently to permit repositioning the suction cup1904. Once properly positioned, the slidable needle 1906 is thenadvanced from the needle catheter 1907 and through the leaflet 1901. Theslidable needle can be a hypotube needle in accordance with an exemplaryembodiment, as disclosed herein. An end of the line 1908 extending fromthe needle 1906 is secured to the leaflet 1901, for example, using aknot or clip (see, for example, U.S. Patent Application Publication No.2014/0114404 A1, which is incorporated herein by reference in itsentirety), or using a pledget fixedly or slidably attached to the line.The length of the line is adjusted to correct leaflet motion, forexample, by observing reduced regurgitation by Doppler ultrasoundimaging. Another end of the line 1908 is then secured to anotherstructure, for example, a ventricular wall, ventricular septum, and/orpapillary muscle, to complete the artificial chord. The device and anyexcess line is removed.

In some embodiments, the line 1908 is similar to, and is deployedanalogously to the artificial chord described in U.S. Pat. No.7,635,386, the entire content of which is incorporated by reference inits entirety.

Embodiments of the disclosed system, device, and method include theability to reposition the suction cup 1904 until the desired positioningis achieved. Another advantage is that the leaflet is captured andimmobilized relative to the line 1908 and needle 1906, which permits amore precise placement of the artificial chord 1908 compared withmethods in which the leaflet is moving relative to the line 1908 at sometime during deployment.

The suction catheter 1905 and suction cup 1904 can be used to securelines to valve tissue in any of the ways described herein. FIG. 20illustrates an embodiment of a method for placing an artificial chord ona posterior leaflet of a mitral valve using the delivery device of FIGS.19A and 19B. In the illustrated embodiment, the suction cup 1904 of thedevice accesses a mitral posterior valve leaflet 2002 through an openingin a ventricular wall 2001. In other embodiments, the leaflet is ananterior leaflet of the mitral valve, or one of the leaflets of thetricuspid valve. In FIG. 20 , the delivery device penetrates theventricular wall above the papillary muscles 2003. In other embodiments,the delivery device penetrates the ventricular wall proximate apapillary muscle, through a papillary muscle, through theintraventricular septum, or at or near the apex of the heart. In otherembodiments, the device can be used to approximate the leafletstogether, as accomplished by the Alfieri stitch.

FIG. 21 illustrates another embodiment of a method for accessing amitral valve leaflet by a transseptal approach from the right atrium tothe left atrium. This approach can be used to tie the mitral valveleaflets together in generally the same manner as described with respectto FIGS. 17A-17B and 18 . However, the pledgets or other type of anchorare disposed on the ventricular side of the leaflets. Those skilled inthe art will understand that a similar approach is useful in accessingthe tricuspid valve leaflet where the delivery device accesses the rightatrium through, for example, one of the superior or inferior vena cava.A variety of different procedures can be performed by accessing theleaflets of the mitral valve or the tricuspid valve from the atrial sideas illustrated by FIG. 21 . The suction cup 2202 can be used in anyprocedure to hold heart tissue, such as a valve leaflet 2205. A needle2203 or other device can penetrate the heart tissue from the atrial sidewhile the tissue is held by the suction cup 2202.

In the example illustrated by FIG. 22 , the distal end of the outercatheter 2201 and the suction cup 2202 captures or engages tissue otherthan a leaflet, for example, to stabilize the delivery device. Forexample, in FIG. 22 , the suction cup 2202 at the distal end of theouter catheter 2201 engages the left ventricular wall 2204 while theneedle (not shown) is deploying a line to the posterior leaflet 2209 ofthe mitral valve. In other embodiments, the suction cup 2202 engagesother tissue, for example, a ventricular wall at or near the apex, anatrial wall, the intraventricular septum, or the interatrial septum,which permits accessing any of the mitral or tricuspid valve leafletsfor placing one or more artificial chords.

FIG. 23 illustrates an embodiment of an artificial chord 2301 deliveredaccording to any of the approaches illustrated in FIGS. 20-22 . In theillustrated embodiment, a first end of the artificial chord 2301 issecured to the anterior mitral valve leaflet 2302 and a second end isanchored at an outside surface of the ventricular wall 2303. Otherembodiments are anchored at another location, for example, within themyocardium, to a papillary muscle, to the intraventricular septum, or toa natural chord or artificial chord, such as a line. Suitable anchors2304, 2305 include pledgets, knots, clips, discs, hooks, barbs, and/oradhesives.

The methods and devices described herein are not limited to use withinthe mitral valve of the heart. They can be used in any heart valve orother valve tissue in the body, such as the tricuspid valve, in whichleaflets are to be repaired, coapted, or otherwise repositioned.

Further, although some of the embodiments have been described herein inthe context of a particular implementation in a particular environmentfor a particular purpose, those of ordinary skill in the art shouldrecognize that its usefulness is not limited thereto and that thevarious embodiments can be beneficially implemented in any number ofenvironments for any number of purposes. Accordingly, the claims setforth below should be construed in view of the full breadth and spiritof the embodiments as disclosed herein. While the foregoing descriptionincludes many details and specificities, it is to be understood thatthese have been included for purposes of explanation only, and are notto be interpreted as limitations of the various embodiments.Modifications to the embodiments described above can be made withoutdeparting from the spirit and scope of this description.

What is claimed is:
 1. A method comprising: advancing a suction cup at adistal end of a suction catheter into a heart chamber; contacting thesuction cup to a heart valve leaflet; and partially axially collapsingthe suction cup while applying a negative pressure through the suctioncatheter and the suction cup and contacting the suction cup to the heartvalve leaflet.
 2. The method of claim 1, wherein contacting the suctioncup to the heart valve leaflet comprises contacting the suction cup to aheart valve leaflet between a heart ventricle and a heart atrium, andwherein the method further comprises: deploying a line to the heartvalve leaflet while applying the negative pressure through the suctioncatheter and the suction cup and contacting the suction cup to the heartvalve leaflet; and anchoring the line to a ventricular wall of the heartventricle to couple the heart valve leaflet to the ventricular wall. 3.The method of claim 1, wherein contacting the suction cup to the heartvalve leaflet comprises contacting the suction cup to a heart valveleaflet between a heart ventricle and a heart atrium, and wherein themethod further comprises: deploying a line to the heart valve leafletwhile applying the negative pressure through the suction catheter andthe suction cup and contacting the suction cup to the heart valveleaflet; and anchoring the line to a papillary muscle of the heartventricle to couple the heart valve leaflet to the papillary muscle. 4.The method of claim 1, wherein advancing the suction cup at the distalend of the suction catheter into the heart chamber comprises advancingthe suction cup into a heart ventricle, and wherein the method furthercomprises: deploying a first length of line to the heart valve leafletwhile applying the negative pressure through the suction catheter andthe suction cup and contacting the suction cup to the heart valveleaflet; contacting the suction cup to a second location on the heartvalve leaflet; deploying a second length of line to the second locationon the heart valve leaflet, the first length of line and the secondlength of line being secured together, and the first length of line andthe second length of line being secured to a line; and anchoring aproximal portion of the line to a ventricular wall of the heartventricle.
 5. The method of claim 4, further comprising deploying aconnector to hold the first length of line and the second length of linetogether.
 6. The method of claim 1 further comprising: providing ahypotube needle into the heart chamber, at least a portion of a linebeing configured to be stored within a lumen of the hypotube needle;puncturing the heart valve leaflet using the hypotube needle whileapplying the negative pressure through the suction catheter and thesuction cup and contacting the suction cup to the heart valve leaflet;and extending a portion of the line out of the lumen of the hypotubeneedle to secure the line to the heart valve leaflet.
 7. The method ofclaim 6, wherein: advancing the suction cup at the distal end of thesuction catheter into the heart chamber comprises advancing the suctioncup into a heart ventricle; providing the hypotube needle into the heartchamber comprising providing the hypotube needle into the heartventricle; puncturing the heart valve leaflet using the hypotube needlecomprises inserting the hypotube needle through the heart valve leafletto position an opening of the hypotube needle on an atrial side of theheart valve leaflet; and extending the portion of the line out of thelumen of the hypotube needle comprises deploying the portion of the linethrough the opening of the hypotube needle on the atrial side of theheart valve leaflet.
 8. The method of claim 1 further comprising:providing a needle comprising a lumen configured to store at least aportion of a line, and a piercing element at a distal end of the needlecomprising an auto incisor; positioning the needle against the heartvalve leaflet; and actuating the auto incisor at the distal end of theneedle to puncture the heart valve leaflet.
 9. The method of claim 1,further comprising: positioning a first anchor over an atrial side ofthe heart valve leaflet; positioning a second anchor over an atrial sideof a second heart valve leaflet; and providing a line between the firstanchor and the second anchor, the line comprising at least a portionextending around ventricular sides of the heart valve leaflet and thesecond heart valve leaflet to pull the heart valve leaflet and thesecond heart valve leaflet together.
 10. The method of claim 9, furthercomprising deploying to a ventricular side of the second heart valveleaflet a connector coupled to the line.
 11. A method comprising:providing a suction cup at a distal end of a suction catheter;contacting the suction cup to a cardiac tissue; and partially axiallycollapsing the suction cup while applying a negative pressure throughthe suction catheter and the suction cup and contacting the suction cupto the cardiac tissue.
 12. The method of claim 11, wherein contactingthe suction cup to the cardiac tissue comprises contacting the suctioncup to an outside surface of a ventricular wall of a heart ventricle,and wherein the method further comprises deploying a line, whileapplying the negative pressure through the suction catheter and thesuction cup and contacting the suction cup to the outside surface of theventricular wall, through the ventricular wall to a heart valve leafletbetween the heart ventricle and a heart atrium.
 13. The method of claim12, wherein: contacting the suction cup to the outside surface of theventricular wall comprises contacting the suction cup to an outsidesurface of a left ventricular wall; and deploying the line through theventricular wall to the heart valve leaflet comprises deploying the linethrough the left ventricular wall and securing the line to a heart valveleaflet of a mitral valve.
 14. The method of claim 11, whereincontacting the suction cup to the cardiac tissue comprises contactingthe suction cup to an atrial wall, an intraventricular septum, or aninteratrial septum.
 15. The method of claim 11, wherein contacting thesuction cup to the cardiac tissue comprises contacting the suction cupto a ventricular side of a heart valve leaflet, and wherein the methodfurther comprises: providing a needle to the ventricular side of theheart valve leaflet; and advancing the needle through the heart valveleaflet to position an opening of the needle on an atrial side of theheart valve leaflet, while applying the negative pressure through thesuction catheter and the suction cup; and deploying at least a portionof a line to the atrial side of the heart valve leaflet while theopening of the needle is on the atrial side of the heart valve leaflet.16. The method of claim 15, wherein the at least a portion of the lineis configured to be stored in a lumen of the needle, and whereindeploying the at least a portion of the line on the atrial side of theheart valve leaflet comprises releasing the at least a portion of theline through the opening of the needle.
 17. The method of claim 11,further comprising: advancing the suction cup at the distal end of thesuction catheter into a heart ventricle through a ventricular wall ofthe heart ventricle at a location above papillary muscles of the heartventricle, wherein contacting the suction cup to the cardiac tissuecomprises contacting the suction cup to a heart valve leaflet that isbetween the heart ventricle and a heart atrium; and securing a line tothe heart valve leaflet that is between the heart ventricle and theheart atrium.
 18. The method of claim 11, further comprising: advancingthe suction cup at the distal end of the suction catheter into a heartventricle through a papillary muscle of the heart ventricle, anintraventricular septum, or a heart apex, and wherein contacting thesuction cup to the cardiac tissue comprises contacting the suction cupto a heart valve leaflet that is between the heart ventricle and a heartatrium; and securing a line to the heart valve leaflet that is betweenthe heart ventricle and the heart atrium.
 19. The method of claim 11further comprising: providing a needle comprising a lumen configured tostore at least a portion of a line; and puncturing the cardiac tissueusing the needle to secure the line to the cardiac tissue whilecontacting the suction cup to the cardiac tissue and partially axiallycollapsing the suction cup.
 20. The method of claim 19, furthercomprising: advancing the suction cup at the end of the suction catheterinto a heart chamber, wherein contacting the suction cup to the cardiactissue comprises contacting the suction cup to the cardiac tissue whilethe suction cup is in the heart chamber; and advancing the needle out ofa distal end of the suction cup for puncturing the cardiac tissue.